AHA Coding Clinic 1st Quarter 2018 – Key Highlights

Coding Clinic 1st Quarter 2018 (effective with discharges starting February 18) unsurprisingly did not include any significant changes since the previous Coding Clinic release was more extensive. It is a good sign that many of the controversial and pressing issues like COPD with pneumonia sequencing has been addressed and now we are now left with coding guidance for Adult Dandruff (Pityriasis Capitis Simplex).

Below are a few highlights from the latest release:

Uncertain Diagnosis “Concern for”

Coding Clinic has confirmed that documentation of “concern for” should be treated as an acceptable “uncertain diagnosis” which, in the inpatient setting can be coded if the diagnosis is documented as such at the time of discharge

In addition to “”probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” coders can now accept “concern for”

For example, if the attending documents on the discharge summary: “CT chest was concerning for pneumonia”, it should be captured as a final diagnosis